Nausea and Vomiting in Pregnancy: Therapeutics
The treatment of nausea and vomiting during pregnancy in the emergency department setting can be intimidating. Nausea is a common symptom of pregnancy and is reported in up to 80% of pregnant women. Of this group, nearly 50% will experience some sort of vomiting or retching-like symptoms.
Defining Hyperemesis Gravidarum
The most severe end of this spectrum is termed hyperemesis gravidarum, which is estimated to impact nearly 1% of all pregnancies. Variably defined, the diagnosis incorporates the following characteristics:
- Persistent vomiting unrelated to other underlying pathology.
- Measure of starvation (I.e. ketonemia vs ketonuria).
- Often a loss of at least 5% of pre-pregnancy weight.
Clinical Assessment and the PUQE Index
The Pregnancy-Unique Quantification of Emesis and Nausea Index (PUQE Index) has been developed to help clinicians assess the severity of a patient’s symptoms based on the patient’s own perception. Specifically, the index includes measures that discuss the symptom severity, desire for treatment, and potential effects of treatment on the fetus as they pertain to clinical decision making. Based on three questions, expecting mothers can have a score up to 15.
Overall, the clinician’s decision for treatment and disposition of this patient population should be based on the factors outlined in the following scoring system:
| PUQE Index Score | Severity Category |
|---|---|
| Score ≤ 6 | Mild |
| Score 7-12 | Moderate |
| Score ≥ 13 | Severe |
Evidence-Based Challenges in Therapeutics
Treating these patients is made even more challenging given the gaps of knowledge that inherently exist surrounding the safety and efficacy of many pharmacologic therapies used to treat expecting mothers. Notably, Matthews et al in their review of treatment in nausea and vomiting of pregnancy concluded in a recent Cochrane Review that “there is a lack of high‐quality evidence to support any particular intervention”. In a more recent Cochrane Review, Boelig et al concluded, “on the basis of this review, there is little high‐quality and consistent evidence supporting any one intervention, which should be taken into account when making management decisions”.
Clinical Risks for Mother and Fetus
As an emergency physician, hyperemesis gravidarum should be approached as a pathological state affecting both mother and fetus. For her fetus, one study by Gross et al (1989) compared fetal outcomes among 64 pregnant women suffering from hyperemesis. Among women with significant weight loss, fetal outcomes were complicated by small birth weight and fetal growth restriction. A systematic review and meta-analysis of literature surrounding the effect of hyperemesis gravidarum on fetal outcomes found babies born to mothers who suffered from hyperemesis gravidarum were also more likely to be born prematurely. However, there are not data supporting increased risk of congenital malformation among these individuals. For the mother, most harm caused is a result of the potential nutritional deficits of which they are at risk.